BridgeSpan Standard Bronze Plan
BridgeSpan Health
Plan overview
Medical deductible
Individual: $9200
Family: $18400
Per Person: $9200
Prescription drug deductible
Individual: $0
Family: $0
Per Person: $0
Combined medical and drug out of pocket maximum
Individual: $9200
Family: $18400
Per Person: $9200
Office visit
Primary Doctor
CoPay: $50.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: $5 copay for the first three in-network primary care provider, other practitioner, outpatient mental/behavioral health, or outpatient substance abuse disorder visits combined per year prior to the deductible being met.
Specialist
CoPay: $150.00
CoInsurance: Not Applicable
Covered: Covered
Prescription drug information
Preferred brand drugs
CoPay: Not Applicable
CoInsurance: 0.00% Coinsurance after deductible
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Insulin limit of $35 for a 30 day supply and $105 for a 90-day supply
Non preferred brand drugs
CoPay: Not Applicable
CoInsurance: 0.00% Coinsurance after deductible
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Insulin limit of $35 for a 30 day supply and $105 for a 90-day supply
Generic drugs
CoPay: $25.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Insulin limit of $35 for a 30 day supply and $105 for a 90-day supply
Specialty drugs
CoPay: Not Applicable
CoInsurance: 0.00% Coinsurance after deductible
Covered: Covered
Limit Quantity: 30
Limit Unit: Days per Month
Benefit Explanation: Insulin: Insulin limit of $35 for a 30 day supply and $105 for a 90-day supply
Inpatient coverage
Hospital services
CoPay: Not Applicable
CoInsurance: 0.00% Coinsurance after deductible
Covered: Covered
Inpatient services
CoPay: Not Applicable
CoInsurance: 0.00% Coinsurance after deductible
Covered: Covered
Emergency and urgent care
Emergency room
CoPay: Not Applicable
CoInsurance: 0.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Out of service area coverage is available.
Urgent care facility
CoPay: $100.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Out of service area coverage is available.
Maternity
Labor and delivery hospital stay
CoPay: Not Applicable
CoInsurance: 0.00% Coinsurance after deductible
Covered: Covered
Pre and Postnatal office visit
CoPay: Not Applicable
CoInsurance: 0.00% Coinsurance after deductible
Covered: Covered
Vision
Routine Eye Exams for Children
CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit: Exam(s) per Year
Major dental care
Routine dental checkups for children
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Routine dental checkups for adults
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
These policies have exclusions, limitations, reduction of benefits, terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company (whichever is applicable).